Addressing Disparities in Lung Cancer From a Geographic Perspective

Raymond U. Osarogiagbon, MD

Raymond U. Osarogiagbon, MD of the Baptist Cancer Center in Memphis, Tennessee, shared his insights on the long-term care and outcome disparities of lung cancer in the United States during the International Association for the Study of Lung Cancer 2021 World Conference on Lung Cancer in an interview with Targeted Therapies in Oncology™ (TTO).¹

To address these disparities, he emphasized the need for a comprehensive, proactive approach to corrective interventions, highlighted innovative solutions to the problem of inequity in care, and identified social policy interventions as the best way to make improvements.

TTO: What do we observe at the state level regarding lung cancer deaths?

OSAROGIAGBON: If we disaggre-gated lung cancer as a cause of death at the state level you will find a huge difference between states with the highest per capita death risk due to cancer in the southern and Midwestern United States. On the leaderboard for lung cancer mortality, Kentucky is number 1, Mississippi, number 2, Arkansas number 3, and Tennessee and West Virginia at number 4 and 5. At number 6 is Alabama, and then you have the Carolinas and Louisiana.

What are the differences in lung cancer between men and women and what racial disparities do you see?

We know that the risk of getting lung cancer with the same level exposure to tobacco is different between men and women; women are at higher risk for a lower level of tobacco exposure. It is oftentimes when we’re talking about interventions themselves and access to them, it is men who do better than women.

And if we look at incidence and prevalence by race, we know that predominantly, racial minorities, especially African Americans, and Native Americans, are particularly at higher risk for lung cancer, even at lower levels of tobacco exposure.

What is of particular concern, though, is the emergence of disparities after the point of [diagnosis]—whether it is finding [lung cancer] early, whether the patient receives optimal treatment for it, and whether appropriate follow-up care is provided after diagnosis and treatment. There are striking differences between people on the basis of socioeconomics, race, and other unnecessary factors that are not at the heart of biology.

How do you address the issues surrounding screening for lung cancer?

The problem in lung cancer is most often by the time we find it, it’s too advanced to cure it. Well, now we know screening for lung cancer saves lives. If you find somebody who is ostensibly at risk for lung cancer on the basis of their age and their past history o f smoking, you could do a low-dose CAT scan once a year. This screening is covered [by most insurance] in the United States. And that test given once a year not only allows us to find lung cancer in people who look like they’re doing just fine. But [screening allows] you to find the cancer at a much earlier stage where you can cure it. And when you do that, we have good evidence that you reduce the risk of dying of lung cancer by 20%.²

Despite the evidence of benefit associated with screening, why hasn’t it become routine?

You would think that with such an exciting discovery that suddenly everybody at risk would be lining up to get these tests and every health care provider and every health care organization would be offering it. The moment our public policy said we will pay you to do these tests in these people, [you would think] that everybody would get it.

The challenge is the average penetration of screening to people who are eligible for it in the United States is about 5%. Only 5% of eligible people have had this screening test in the last few years. Conversely, 95% have not.

If you look at the places where the screening facilities are available, and the places where people who are eligible for screening and have received the screening test, the highest states are in the northeast, where up to 15% to 17% of eligible people have been screened.

In the places at the highest levels of lung cancer deaths, screening is consistently less than 5% of eligible people, sometimes as low as 2%. The only exception is Kentucky, the state at number one, where they’re an outlier, with 15% to 16% of the eligible patients screened. There is a geographic disparity regarding access to a life-saving technology that is covered by insurance.

How do we define who is eligible for screening?

A person’s risk determines if they should undergo screening and the most reliable factor to define who is a candidate is patient age. In addition, smoking history, which factors in smoking intensity (ie, the number of pack-years smoked) and length of time since quitting are other factors.

White males are more likely to be eligible for screening than White women, Blacks, Hispanic, and Asian people, even though screening is covered by insurance and can save lives. There is also a striking disparity in access to curative intent—ie, lung cancer surgery. Access to surgery is about 50% in Wyoming or as high as 90% in New Jersey, Massachusetts, and Utah.

Are these disparities observed in clinical trials?

Innovations in treatment arise from findings of clinical trials, but if you evaluate the patient population who participate in trials, the proportion of Black patients involved in lung cancer trials mirrors disparities in geography, demographics, and socioeconomic factors (FIGURE1).

What would your take home messages be to impart to oncologists?

Number one, disparities are preventable. Number two, disparities are incredibly costly. The third thing is that as we begin to focus on preventing, narrowing, and eliminating disparities, we have to understand that the solutions come from multiple levels.

The least effective is the level of blaming the victims of disparities. Patients don’t go in with the idea that they will do something to hurt themselves. A patient with lung cancer who is poor, does not stand up in the morning and decide, “I am so going to make sure I get the wrong treatment today. I don’t care if I die.”

Where is our intervention most successfully deployed? I think it is important to recognize that the level at which we can have the most impact is at the policy level. The second biggest level of impact is at the organizational level.

So take the example of screening. If my organization has not gone to the trouble of providing low-dose screening, a lung cancer screening CT scan program, it does not matter what the patient wants, they won’t get it. It’s not there to get. And then of course, if the provider, who is the next most influential person, is not actively seeking, advising, counseling, and ordering the right care for patients, well, it’s not going to happen either. If the provider has not taken the pains of sharing the knowledge that he or she has with the patient, the patient probably has no access to that knowledge. So when we talk about disparities, I think it is very important for us to get away from the traditional narrow lens that asks, “Who are these people or why do they have such terrible outcomes?” We should recognize that we have seen the enemy, and it is us.

_REFERENCES:

_{1. Osarogiagbon R. Disparities in lung cancer care across the population. Presented at: IASLC 2021 World Conference on Lung Cancer. September 8-14, 2021. Abstract PL01.2. virtual.}

_{2. Cheung LC, Katki HA, Chaturvedi AK, Jemal A, Berg CD. Preventing lung cancer mortality by computed tomography screening: the effect of risk-based versus U.S. Preventive Services Task Force eligibility criteria, 2005-2015. Ann Intern Med. 2018;168(3):229-232. doi:10.7326/M17-2067}